Avoidant and borderline personality disorder patients during the first Covid-19 wave in Norway – a survey-based comparison of therapy changes and patients’ accommodations

Background Patients with personality disorders (PDs) often have insecure attachment patterns and may be especially vulnerable to abrupt treatment changes. Patients with borderline PD (BPD) are often considered vulnerable to treatment interruption due to chronic fear of abandonment. Nonetheless, other PDs are poorly investigated. In the first Covid-19 wave in Norway, in-person treatment facilities and group treatments were strongly restricted from March 12th until May/June 2020. Objectives To examine and compare changes in outpatient treatment for patients with avoidant (AvPD) and BPD during the first Covid-19 wave in Norway, and patients’ reactions to these changes. Methods The study is based on a cross-sectional survey distributed to 1120 patients referred to 12 different PD treatment units on a specialist mental health service level within the Norwegian Network for Personality Disorders. The survey included questions on treatment situation, immediate reactions, and changes during the crisis. From 133 responders (response rate 12%), 40 patients reported BPD and 30 AvPD as diagnosis. Results All patients were followed up from their therapist after March 12th. Almost all patients in both groups expressed satisfaction under the new circumstances. Both groups experienced the same regularity as before, but more AvPD patients reported less than weekly consultations. AvPD patients reported more negative feelings about changes in therapy, and missed the therapy and group members more than the BPD group. Conclusion After the lockdown, BPD patients received a closer follow-up than AvPD patients, and the latter reported more negative feelings related to change in their treatment situation

Improvement of personality functioning among people treated within personality disorder mental health services. A longitudinal, observational study

Objective: Evidence-based personality disorder (PD) treatments are dominated by interventions targeting Borderline PD, although clinical populations characteristically include different PD features and severity. Personality functioning is a new concept intended to capture common features across PDs. This study aimed to investigate longitudinal improvement of personality functioning in a clinical sample assigned to PD treatment. Method: An observational, large, longitudinal study of patients in PD treatments on specialist mental health service levels (N = 1,051). DSM-5 PDs were systematically assessed on referral. Personality functioning was repeatedly assessed (LPFS-BF-2.0), supplemented by symptom distress (anxiety: PHQ-GAD-7, depression: PHQ-9), and social/occupational activity (WSAS, work/study activity). Statistics were linear mixed models. Results: Thirty per cent had personality difficulties below PD threshold. Among PDs, 31% had Borderline (BPD), 39% Avoidant (AvPD), 15% not otherwise specified, 15% other PDs, and 24% > one PD. More severe initial LPFS-BF was associated with younger age, presence of PD and increasing number of total PD criteria. Across PD conditions, LPFS-BF, PHQ-9 and GAD-7 improved significantly (overall effect size 0.9). Mean duration of PD treatment was 15 (SD 9) months. Drop-out rates were low (12%). LPFS-BF improvement-rates were higher for BPD. Younger age was moderately associated with slower PHQ-9 improvement. Work/study activity was initially poor, poorer levels associated with AvPD and younger age, and improvement was non-significant across PD conditions. AvPD was associated with slower WSAS improvement-rates. Conclusion: Personality functioning improved across PD conditions. The results highlight BPD improvements. The study points to challenges concerning AvPD treatment, poor occupational activity and age-related differences

Avoidant Personality Disorder and Social Phobia. Studies of Personality Pathology and Functioning, Childhood Experiences and Adult Attachment

Background: Avoidant Personality Disorder (AvPD) and Social Phobia (SP) are closely related and common disorders both in the community and in clinical settings. Whether the two disorders represent different severity levels of social anxiety disorder is currently in dispute. The relationship between AvPD and SP is probably more complex than previously assumed. Little is known about similarities and differences in personality functioning and psychopathology, temperamental and environmental factors, and the underlying processes related to social discomfort in subjects with AvPD and/or SP, such as attachment styles. We wanted to use the Experiences in Close Relationships (ECR) inventory to assess attachment style; however, the Norwegian version of ECR has previously not been tested in a sample of patients with personality disorders (PDs). Objectives: This thesis aimed to explore differences and similarities in developmental and psychopathological aspects of AvPD and SP through comparison of symptoms, personality pathology and functioning, temperament, childhood experiences/trauma, and attachment styles in patients with AvPD and SP. In this way, we hope to contribute to a more thorough understanding of the psychopathology of AvPD and the relationship between the two disorders. By investigating the psychometric properties of the Norwegian version of ECR in a sample of PDs, we were able to use this instrument to compare attachment styles in AvPD and SP. Materials and methods: Papers I, II, and IV are based on a sample of 91 adult patients with AvPD and/or SP who participated in a multi-site, cross-sectional study. In paper I, we compared three diagnostic groups: one group of patients who had SP and not AvPD; a group who had AvPD and not SP; and a group of patients who had both diagnoses. In papers II and IV, we merged all of the patients with AvPD into one AvPD group with and without concurrent SP and compared them to patients with SP without AvPD, designated as the SP group. Ninety percent of patients in the SP group had generalized SP. Patients were examined using diagnostic interviews and self-report measures, including the Index of Self-Esteem, Severity Indices of Personality Problems, Adult Temperament Questionnaire, Childhood Trauma Questionnaire, Parental Bonding Instrument, and the ECR inventory. In paper III, we examined the psychometric properties of ECR and its two short-forms, ECR-S and ECR-N12, in a sample of 495 patients with PDs. Analyses of the internal consistency, as well as confirmatory and exploratory factor analyses, were conducted. Results: Papers I, II, and IV – Compared with the SP group, patients with AvPD had more symptom disorders and met more criteria for other PDs. They reported more psychosocial problems and more personality dysfunction regarding self-esteem, identity, and relational problems. AvPD predicted personality dysfunction in the identity and relational domains over and above the presence of SP, number of other symptom disorders, and other PDs. Both AvPD and SP were associated with negative childhood experiences. Patients with AvPD reported more severe childhood neglect, most pronounced for physical neglect, compared to patients with SP without AvPD. The difference between the disorders in neglect remained significant after controlling for temperamental differences and concurrent physical, sexual, and emotional abuse. Both SP and AvPD were associated with high levels of attachment anxiety and avoidance, and a large majority of patients in both groups had an insecure attachment style. Patients with AvPD had higher levels of attachment anxiety than patients with SP without AvPD, especially regarding the subfactors “Anxiety for abandonment” and “Separation frustration.” Severity of AvPD was associated with “Anxiety for abandonment” over and above concurrent SP, the number of other symptom disorders, and criteria met for other PDs. The diagnostic groups did not differ significantly in levels of attachment avoidance. Paper III – The internal consistency of ECR was found to be questionable. Confirmatory factor analyses revealed poor model fit for the two factor solution of ECR and ECR-S. The two factor solution of ECR-N12 revealed mediocre fit, indicating a potential for improvement. An exploratory factor analysis indicated five factors representing two somewhat different aspects of attachment avoidance and three aspects of attachment anxiety. This alternative five factor solution was called ECR-FF. Conclusions: Papers I, II, and IV – The results indicate that AvPD involves broader and more severe areas of personality pathology and dysfunction than SP, supporting the conceptualization of AvPD as a PD. Furthermore, childhood neglect could be a risk factor for AvPD and SP, most pronounced for AvPD, and may be one contributing factor to phenomenological differences between AvPD and SP. AvPD seems to be associated with more attachment anxiety than SP. Thus, fear of abandonment may play a significant role in avoidant personality pathology. Paper III – Inferences from scale scores based on ECR should be derived with care in samples with PDs. A revision of ECR and ECR-N12 is warranted, and further studies are needed to investigate the validity of ECR-FF among different clinical samples

Psychometric evaluation of the Norwegian Toronto Alexithymia Scale (TAS-20) in a multi-site clinical sample of patients with personality disorders and personality problems

Objective Psychometric properties of 20-item Toronto Alexithymia Scale (TAS-20) have been widely analyzed, but the validity and psychometric qualities of the TAS-20 in populations with personality disorders are still poorly understood. The aim of the current study was to analyze the factor structure and validity of TAS-20. Method Data were extracted from a multisite clinical sample of patients with personality disorders or personality-related problems referred to specialist mental health services in Norway. Results With one exception, TAS-20 revealed acceptable psychometric properties. Variations of TAS-20 are associated with other clinical measures of distress and severity. Anxiety disorders, borderline, and avoidant personality disorders were all highly related to levels of TAS-20. The TAS-20 also revealed unique variance not accounted for by subjective distress, symptom disorders, or dysfunctional personality traits. Conclusion The TAS-20 is a relevant instrument for use in assessment of personality disorders, but one subscale should be improved

A psychometric analysis of the structured clinical interview for the DSM-5 alternative model for personality disorders module I (SCID-5-AMPD-I): Level of personality functioning scale

The current study aims to examine the psychometric properties of the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I (SCID-5-AMPD-I) assessing the Level of Personality Functioning Scale (LPFS) in a heterogeneous sample of 282 nonpsychotic patients. Latent variable models were used to investigate the dimensionality of the LPFS. The results indicate that the LPFS, as assessed by the SCID-5-AMPD-I, can be considered as a unidimensional construct that can be measured reliably across a wide range of the latent trait. Threshold parameters for the 12 indicators of the LPFS increased gradually over the latent scale, indicating that the five LPFS levels were ordered as predicted by the model. In general, the increase of threshold parameters was relatively small for the shift from Level 2 to Level 3. A better distinction among the different severity levels might be obtained by fine-tuning the interview guidelines or the Level 2 indicators themselve

A psychometric analysis of the structured clinical interview for the DSM-5 alternative model for personality disorders module I (SCID-5-AMPD-I): Level of personality functioning scale

The current study aims to examine the psychometric properties of the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I (SCID-5-AMPD-I) assessing the Level of Personality Functioning Scale (LPFS) in a heterogeneous sample of 282 nonpsychotic patients. Latent variable models were used to investigate the dimensionality of the LPFS. The results indicate that the LPFS, as assessed by the SCID-5-AMPD-I, can be considered as a unidimensional construct that can be measured reliably across a wide range of the latent trait. Threshold parameters for the 12 indicators of the LPFS increased gradually over the latent scale, indicating that the five LPFS levels were ordered as predicted by the model. In general, the increase of threshold parameters was relatively small for the shift from Level 2 to Level 3. A better distinction among the different severity levels might be obtained by fine-tuning the interview guidelines or the Level 2 indicators themselve

The Incremental Utility of Criteria A and B of the DSM-5 Alternative Model for Personality Disorders for Predicting DSM-IV/DSM-5 Section II Personality Disorders

The DSM-5 Alternative Model for Personality Disorders (AMPD) includes two main criteria: moderate or greater impairment in personality functioning (Criterion A) and the presence of one or more pathological personality traits (Criterion B). The aim of the study was to investigate the incremental utility of Criteria A and B for predicting DSM-5 Section II personality disorders (PD). The sample (N = 317) consisted of three well-defined groups: non-clinical participants (n = 35), psychiatric patients with PD (n = 193), and without PD (n = 83). All were assessed using the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I (SCID-5-AMPD-I): Level of Personality Functioning Scale (LPFS), and the Personality Inventory for DSM-5 (PID-5). Logistic regression analyses showed that the SCID-5-AMPD-I could predict the presence of PDs in general, and the three specific PDs that were investigated (i.e., Antisocial, Borderline, and Avoidant PDs). The PID-5 domains enhanced prediction of the specific PDs, but not the presence of PDs in general, when entered in the second step. Our results support the AMPD model: Criterion A predicted the presence of DSM-5 Section II PDs in general, whereas measures of Criterion B incremented prediction of Antisocial, Borderline, and Avoidant PDs

Vulnerability of personality disorder during COVID-19 crises: a multicenter survey of mental and social distress among patients referred to treatment

Background Relational and emotional problems, dysregulation, self-harming or substance abuse often characterize personality disorders (PD). In Norway, COVID-19 restrictions led to an abrupt shutdown of services from 12 March 2020 also including specialized PD treatments. Aims The objective of this study was to investigate social and mental distress among patients with PDs during the first COVID-19 wave. Design A survey was distributed after the first COVID-19 wave (June–October 2020) among 1120 patients from 12 PD treatment units. Results The response rate was 12% (N = 133). The survey reflected impairment of occupational activity (53% <50% activity last 6 months), life quality (EQ-5D-VAS: 56, SD 19), and personality functioning (LPFS-BF ≥12: 81%, 35% avoidant PD, 44% borderline PD) and high levels of depression and anxiety (PHQ-9 ≥ 10: 84%, GAD-7 ≥ 10: 68%), 49% with health-related anxiety. Problem increase was reported for anxiety (28%), depression (24%), aggression (23%), substance use (14%), and 70% of parents had more child-care difficulties. Self-destructive behaviors (26%) did not increase. The majority (78%) reported increased or unchanged social isolation and loneliness. Occupational activity declined with negative effects on part-time jobs/rehabilitation. Therapist contact was mainly telephone-based (63% ≥ weekly contact). More severe personality problems, current depressive symptoms, and self-harming before 12 March were associated with more frequent consultations. Conclusion The survey confirms severe, enhanced levels of mental distress among patients receiving telephone-based consultations as the main alternative to specialized PD treatment during the COVID-19 shutdown. The most vulnerable patients received more frequent consultations and self-destructive actions did not increase

Vulnerability of personality disorder during the Covid-19 crises – a multicenter survey of treatment experiences among patients referred to treatment

Background: The societal shutdown due to the Covid-19 pandemic involved mental health services for personality disorder (PD) and was introduced from 12 March 2020 in Norway. Rapid implementa- tion of treatment modifications was required for patients typically characterized by insecure attach- ment and vulnerability to separation. Aim: To investigate immediate reactions to the shutdown of services; alternative treatment received; and differences related to age in a clinical sample of patients with PD. Design: A survey performed from June to October 2020 (after the first Covid-19 wave) among 1120 patients from 12 units offering comprehensive group-based PD programs. Results: The response-rate was 12% (N¼133). Negative feelings of anxiety, sadness, and helplessness were noteworthy immediate reactions, but the dominating attitude was accommodation. Younger patients (Conclusion: The survey confirms a radical modification from comprehensive group-based PD pro- grams to telephone consultations, low availability of digital consultations and group treatments. Taking a short-term, first wave perspective, the survey indicates a noteworthy capacity among poorly functioning patients for accommodating to a clearly challenging situation, as well as considerable con- cern about treatment progress